There is a program fee, but each applicant who is a U



Khmer Language and Culture Study Program

Application 2020

Deadline extended to March 31, 2020

APPLICATION FORM (U.S citizens only)

Personal Information

Name: (First) (Middle) (Last name)

Permanent Home Address:

_______________________________________________________________________________

Current Mailing Address

_______________________________________________________________________________

Professional E-mail:

And *Personal Email:

Telephone: Fax:

(Email will be the primary means of communication for this program)

Times best reached at these numbers:_________________________________________________

Is the above information valid until the time immediately prior to departure (June, 2020)?

□ Yes □ No

If the answer is No, provide alternative addresses/contact numbers where you can be reached immediately prior to departure.

Address: _______________________________________________________________________________

_______________________________________________________________________________

E-mail: Telephone: Fax:

Times best reached at these numbers: _____________________________________________

Valid from (month/day/year) ___________________________ to (month/day/year) ____________

(Telephone numbers are needed for the Khmer interview, an integral part of the application process.)

Please check the appropriate box:

□ U.S. Citizen □ Permanent Resident □ Neither (not eligible for financial support)

Social Security Number (if applicable): #

Educational Background

List all college or university training undertaken to date. List current degree program first. Write on the back if extra space is needed

|Institution Completed |Department/Major |Degree & Date |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

Pre-Summer Abroad (choose one):

□ Junior □ Senior □ M.A. student □ Ph.D. student

□ Teacher (grade) _____ □ Administrator □ Other

Students please indicate institution, department/program, anticipated degree and date. Teachers list school, grade/level, and subject area. Administrators include school or institution. Others — please explain.

_______________________________________________________________________________

_______________________________________________________________________________

Post-Summer Abroad:

□ Same as Pre-Summer Abroad status If different, please choose from the followings:

□ Junior □ Senior □ M.A. student □ Ph.D. student

□ Teacher (grade) _______ □ Administrator □ Other

Students please indicate institution, department/program, anticipated degree and date. Teachers list school, grade/level, and subject area. Administrators include school or institution. Others — please explain.

_______________________________________________________________________________

_______________________________________________________________________________

Future Plans

If you are not a teacher, do you intend to pursue a teaching career? □ Yes □ No

If you intend to pursue a teaching career, in what field?

_______________________________________________________________________________

Knowledge of Khmer

Have you had two years of Khmer at college or university? □ Yes □ No

Please list all training you have had in Khmer with the following items: name of the institution (college or university, Peace Corps, etc.), the type of instruction you received (academic course, private tutoring, etc.), the length of your training (3 semesters, 2 years, etc.), and the skills emphasized (speaking, reading, etc.).Write on the back if extra space is needed.

|Institution |Type of instruction |Duration |Skill emphasis |

| | | | |

| | | | |

| | | | |

| | | | |

Residence in Cambodia

Have you lived in Cambodia? □ Yes □ No

If you have spent any time in Cambodia, please list briefly the length of time you spent there, your purpose for going, and the degree to which you relied on your ability to use Khmer in your daily life. Write on the back if extra space is needed. Example: 2 years/Peace Corps/Completely; 6 months/living with relatives/occasionally; 4 weeks/tourism/very little.

|Dates |Purpose of Visit |Use of Khmer |

| | | |

| | | |

| | | |

Residence of Family and Friend Who Reside or Work in Cambodia

If you have family or friends who reside or work in Cambodia during the time that you will be there, list their name and contact numbers in case of emergencies.

|Name | E-mail: |Telephone |

| | | |

| | | |

References

List the three people you have asked to write letters of recommendations for you:

|Name |Position |Email |Phone number |

| | | | |

| | | | |

Financial Aid

Are you an applicant for financial aid (U.S. citizens and permanent residents only)? □ Yes □ No

SEASSI or Other Program

The Advanced Study of Khmer Language program cooperates with the Southeast Asian Studies Summer Institute. It ensures that the applicants who apply to both programs are accepted by the one which is more appropriate for them.

Are you applying to SEASSI? □ Yes □ No

If you are applying to a different program, please tell us what it is:

_______________________________________________________________________________

Personal Statement

Write your Personal Statement in the space below. Write on the back or attach additional sheet(s) if extra space is needed (remember to put your name on every additional sheet you submit). Your Personal Statement should outline your academic and/or career goals, and indicate how participation in the program will help you achieve those goals.

If there are any further details regarding your prior education and/or training in Khmer that you think may be useful for the selection, please discuss in the Personal Statement.

Applicant’s signature:__________________________________Date:____________________________

APPLICANTS MUST ANSWER ALL QUESTIONS ON THIS APPLICATION. FAILURE TO DO SO MAY INVALIDATE THE APPLICATION

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